David C. Yang

Comparison of Trends and Outcomes of Carotid Artery Stenting and Endarterectomy in the United States, 2001 to 2010

Background—Given the controversy regarding whether carotid endarterectomy (CEA) or carotid artery stenting (CAS) may be superior for stroke prevention, it is uncertain how recent clinical evidence, guidelines, and reimbursement policies have influenced the volume and outcomes after these procedures. Methods and Results—We conducted a serial, cross-sectional study with time trends of patients undergoing CAS (n=124 265) and CEA (n=1 260 647) between 2001 and 2010 from the Nationwide Inpatient Sample database. During the 10-year period, the frequency of CEA declined, whereas CAS use slowly increased. After multivariate propensity score–matched analysis, CAS was associated with an increased risk of death (odds ratio [OR], 1.69; 95% confidence interval [CI], 1.40–2.04), stroke (OR, 1.43; 95% CI, 1.23–1.66), and major adverse events including death, stroke, and myocardial infarction (OR, 1.25; 95% CI, 1.13–1.39). In asymptomatic patients, there was no significant difference in major adverse events (OR, 1.08; 95% CI, 0.92–1.20; P=0.16 [P <0.001 for interaction between procedure type and symptom status]) between CAS and CEA. Importantly, there was a significant improvement in CAS outcomes during the course of 10 years (reduction in death [OR, 0.51; 95% CI, 0.49–0.67; P for trend=0.03] and major adverse events [OR, 0.75; 95% CI, 0.66–0.84; P for trend=0.05] comparing years 2010 versus 2001). Conclusions—In US hospitals between 2001 and 2010, CAS was associated with worse in-hospital outcomes, partly attributable to selection and ascertainment bias. Asymptomatic patients undergoing CAS versus CEA had similar adjusted rates of major adverse events. CAS outcomes improved significantly during the course of the decade likely attributable to improvements in patient selection, operator skills, and technological advancements.

Rate of percutaneous coronary intervention for the management of acute coronary syndromes and stable coronary artery disease in the United States (2007 to 2011).

Although the benefit of percutaneous coronary interventions (PCIs) for patients presenting with acute coronary syndromes (ACS) has been established in numerous studies, the role of PCI in stable coronary artery disease (CAD) remains controversial. With the publication of the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluations trial and the appropriate use criteria for coronary artery revascularization, we sought to examine the impact of these treatment strategies and guidelines on the current practice of PCI in United States. We conducted a serial cross-sectional study with time trends of patients undergoing PCI for ACS and stable CAD from 2007 to 2011. The annual rate of all PCI decreased by 27.7% from 10,785 procedures per million adults per year in 2007 to 2008 to 7,801 procedures per million adults per year in 2010 to 2011 (p=0.03). Although there was no statistically significant decrease in the PCI utilization for ACS from 2007 to 2011, PCI utilization for stable CAD decreased by 51.7% (from 2,056 procedures per million adults per year in 2008 to 992 procedures per million adults per year in 2011, p=0.02). Hospitals with a higher volume of PCI experienced a more significant decrease. Decrease in PCI utilization for stable CAD was statistically significant for patients with Medicare and private insurance/health maintenance organization (44.5%, p=0.03 and 59.5%, p=0.007, respectively). In conclusion, the rate of PCI decreased substantially starting from 2009 in the United States. Most of the decrease was attributed to the reduction in PCI utilization for stable CAD.

Trends in hospital treatments for peripheral arterial disease in the United States and association between payer status and quality of care/outcomes, 2007–2011

This study sought to identify the temporal trends of presenting diagnoses and vascular procedures performed for peripheral arterial disease (PAD) along with the rates of procedures and in‐hospital outcomes by payer status.

Pharmacotherapy for the reduction of stent thrombosis

The benefits of percutaneous coronary intervention (PCI) can be offset by periprocedural complications such as acute vessel closure and stent thrombosis in the absence of adequate antiplatelet and antithrombotic therapy. Additionally, conditions occurring after 30 days post-PCI, such as in-stent restenosis or late stent thrombosis can occur. Excess antithrombotic therapy, on the other hand, carries a risk of major gastrointestinal or intracranial bleeding as well as vascular access site bleeding complications. In this review, evidence related to the various pharmacological agents for reduction of stent thrombosis available to clinicians during and after PCI will be explored.

COST-EFFECTIVE AND SAFE MANAGEMENT OF LOW-RISK CHEST PAIN WITH AN OUTPATIENT PROTOCOL INVOLVING CONTRAST-ENHANCED STRESS ECHOCARDIOGRAPHY

Chest pain accounts for over 7 million emergency department (ED) visits annually in the U.S., with associated inpatient costs of over

Pharmacotherapy During Percutaneous Coronary Interventions

11 billion. Most patients with low risk features are determined to have a non-cardiac etiology of their chest pain. This study compares clinical outcomes and cost

Hospital length of stay and clinical outcomes in older STEMI patients after primary PCI: a report from the National Cardiovascular Data Registry.

Percutaneous arterial catheterization and transluminal dilatation of stenotic vessels were first described by Charles T. Dotter and Melvin P. Judkins in their seminal paper published in 1964 (1). With the advent of contemporary coronary angioplasty and stenting techniques for patients with coronary artery disease (CAD) and acute coronary syndromes (ACS), the procedure has now been termed percutaneous coronary intervention (PCI). While PCI has done much in the modern era to improve patient outcomes in the face of acute myocardial infarction as well as in disabling cardiac angina, its benefits can still be limited by periprocedural complications such as acute vessel closure and stent thrombosis as well as conditions occurring after 30 days post-PCI, such as in-stent restenosis or late stent thrombosis. Additionally, catheter and wire associated thrombus formation can occur during PCI in the absence of adequate anticoagulation. Excess anticoagulation on the other hand carries a risk of major gastrointestinal or intracranial bleeding as well as vascular access bleeding complications. Stent thrombosis is a rare, but serious complication of PCI and usually presents as death or ST-elevation myocardial infarction. Coronary stents are generally made of stainless steel or cobalt chromium alloys rendering them thrombogenic until they are completely covered by endothelial tissue. The timing of complete endothelialization is variable and depends on whether the implanted stent is bare metal or drug-eluting, as well as which type of anti-proliferative drug the stent is coated with. Stent thrombosis can be described based on its timing relative to stent placement and is associated with a number of different risk factors (Table 1). Acute stent thrombosis occurs within 24 hours of PCI and in one pooled analysis, approximately 80 percent of all bare metal stent (BMS) thromboses occurred within this acute period (2). Subacute stent thrombosis occurs up to 30 days after PCI and this time period encompasses the majority of all thrombotic events observed in both BMS and drug-eluting stents (DES) (3). Stent thrombosis after 30 days and up to one year post-PCI is referred to as late stent thrombosis and seems to occur with equal frequency in BMS and DES, particularly in the absence or cessation of dual antiplatelet therapy with aspirin or clopidogrel (4-5). Occurring even less commonly at greater than one year post-PCI, very late stent thrombosis appears to be associated with DES more than BMS and is thought to be related to delayed neo-intimal coverage as well as ongoing vessel inflammation (6). Current ACC/AHA guidelines make a number of recommendations regarding the concurrent use of antiplatelet, antithrombotic, and